RHD in Nepal from perspective of Preventive Medicine.

1. Rheumatic Heart Disease
Presented by : Anish Luitel
Submitted to : Dr. Surya B. Parajuli
Department of Community Medicine,BMCTH

2. Learning Objectives….
• Introduction to RHD
• Burden of RHD in world and in Nepal
• Epidemiological Factors
• Clinical Presentation, Diagnosis and treatment of RHD
• Preventive measures
• The Nepal RF/RHD Prevention and control Program

3. Introduction
• RHD is a chronic heart condition caused by acute rheumatic fever (ARF).
• Rheumatic Heart Disease (RHD) is the most common acquired heart disease
in children in developing countries.
• RHD is an important public health problem in Nepal, which can be
prevented and controlled.
• Thousands of deaths in children and young adults annually are attributed to
RHD in Nepal
Man Bahadur KC. Rheumatic Heart Disease in Nepal:
Current Scenario,2016

4. Problem Statement
• It affects 39 million people worldwide.
• Every year, the disease claims 291,000 lives, accounting for about 2% of
all deaths from cardiovascular disease—the number one cause of death
globally.
• Rheumatic heart disease is diseases of POVERTY.
• Rheumatic heart disease is a preventable yet serious public health
problem in low- and middle-income countries.
https://world-heart-federation.org/what-we-
do/rheumatic-heart-disease/

5. RHD In Nepal
• A number of studies have attempted to document prevalence of RHD in
Nepal.
• Most of these prospective surveys have been carried out either in schools or
in school aged children in communities.
• All these studies showed the prevalence of RHD among school children to
be between 0.9-1.35 per thousand.

6. Man Bahadur KC. Rheumatic Heart Disease in Nepal:
Current Scenario,2016
Few points to think about……
• What shall be the prevalence in rural areas where RHD is more
prevalent.
• What about seriously ill and old age polulation with RHD, are they
included ?
• Are these survery done systematically in Nepal ?

7. • RHD is among the top three reasons for admission in cardiology
department and also second most common cause of cardiac surgery at
Shahid Gangalal National Heart Center (SGNHC).
Man Bahadur KC. Rheumatic Heart Disease in Nepal:
Current Scenario,2016

8. Environmental Factors
Poverty Undernutrition.
Overcrowding Poor housing
Rural Living Urban Slum Residence
Host Factors
Children age 5–14 years (ARF)
RHD more prevalent in age group
25-40 yrs.
More commonly affects females
Agent Factors
Group A beta-
hemolytic streptococci (GABHS)
Rheumatogenic Strain particularly
M type 5.
Epidemiological
Triad
Sore
throat
ARF
RHD

9. Pathogenesis

10. Clinical Manifestations of ARF
1) JOINT INVOLVEMENT :
Most common manifestation (60–75%)
Migratory polyarthritis
2) HEART INVOLVEMENT
Up to 60% of patients with ARF progress to RHD
Pancarditis
Valvular damage is the hallmark of rheumatic carditis.(Mitral valve)

11. 3) SYDENHAM’S CHOREA
Found mainly in females.
Affect particularly the head (causing characteristic darting movements of the
tongue) and the upper limbs
4) SKIN MANIFESTATIONS
a) Erythema marginatum
Begins as pink macules that clear centrally,
leaving a serpiginous, spreading edge.
The rash is evanescent, appearing and
disappearing before the examiner’s eyes.

12. b) Subcutaneous nodules
Occur as painless, small (0.5–2 cm), mobile lumps
beneath the skin
5) FEVER
High grade

13. Clinical Manifestations of RHD
Symptoms of RHD may not be noticed for many years. When they do develop,
symptoms depend on which heart valves are affected and the type and severity
of the damage.
• Chest pain or discomfort
• Shortness of breath
• Swelling of the stomach, hands or feet
• Fatigue
• Rapid or irregular heartbeat

14. Diagnosis
2002–2003 WHO Criteria for the Diagnosis of Rheumatic Fever and
Rheumatic Heart Disease (Based on the 1992 Revised Jones Criteria)
Major manifestations: Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules

15. Minor manifestations
Clinical: fever, Polyarthralgia
Laboratory: Elevated erythrocyte sedimentation rate or
leukocyte count
Electrocardiogram: prolonged P-R interval
Supporting evidence of a preceding streptococcal infection
within the last 45 days
Elevated or rising anti-streptolysin O or other streptococcal antibody, or
A positive throat culture, or
Rapid antigen test for group A streptococcus, or
Recent scarlet fever

16. Diagnostic Categories Criteria
Primary episode of rheumatic fever Two major or
One major and two minor manifestations plus
evidence of preceding group A streptococcal Infection
Recurrent attack of rheumatic fever in a patient
without established rheumatic heart disease
Two major or
One major and two minor manifestations plus
evidence of preceding group A streptococcal infection
Recurrent attack of rheumatic fever in a patient
with established rheumatic heart disease
Two minor manifestations plus
Evidence of preceding group A streptococcal
Infection
Chronic valve lesions of rheumatic heart disease
(patients presenting for the first time with pure
mitral stenosis or mixed mitral valve disease and/ or
aortic valve disease)
Do not require any other criteria to be diagnosed as
having rheumatic heart disease.

17. Treatment of RHD
• There is no cure for rheumatic heart disease and the damage to the heart
valves are permanent.
• Patients with severe rheumatic heart disease will often require surgery to
replace or repair the damages valve or valves
• Medication may also be needed to treat symptoms of heart failure or heart
rhythm abnormalities
Surgical Treatment : percutaneous transseptal mitral commissurotomy
(PTMC), mitral and tricuspid valve repair, and valve replacement surgeries.

18. Government Initiatives in Treatment of RHD
• The treatment of RHD is expensive, majority of Nepalese population are
unable to afford the treatment.
• Government of Nepal has been providing free of cost surgeries for children
under 15, adults over 75 and free PTMC for all population.
• It also provides financial assistance to the needy patients who need valve
surgery. Government of Nepal also provides 200 free valves for poor patient
in SGNHC and 100 valves for Manmohan Cardiothoracic Vascular and
Transplant Centre.
Man Bahadur KC. Rheumatic Heart Disease in Nepal:
Current Scenario,2016

19. Prevention
A) Primary Prevention
1) Health Promotion
i) Health Education
ii) Environmental Modification : Provision of safe water
Improvement of housing
iii)Nutritional Modification: Improvement in nutrition
iv) Lifestyle and behavioral changes

20. 2)Specific Protection :
i) Chemical Prophylaxis
• Identify the patients with sore throat and treat with Penicillin
• A single intramuscular injection of 1.2 million units of benzathine benzyl
penicillin for adults and 600,000 units for children is adequate, or oral penicillin
(Penicillin V or Penicillin G) should be given for 10 days
But……….
Is it practicable in countries like ours ?
What else can be done?.............concentrate on High risk group.

22. B) Secondary Prevention
• Involves prevention of recurrences of RF.
• It is a more practicable approach, especially in developing countries.
• It consists in identifying those who have had RF and giving them one
intramuscular injection of benzathine benzyl penicillin (1.2 million units in
adults and 600,000 units in children) at intervals of 3 weeks.

24. THE NEPAL RF/RHD PREVENTION AND
CONTROL PROGRAM
• Government of Nepal funded heart valve replacements for low-income
RHD patients . But, this tertiary approach generated lengthy waiting lists and
many patients with end-stage disease died awaiting surgery.
• Then, the government of Nepal became interested in developing a control
program, which could decrease the morbidity and mortality in children and
represent a more cost-effective strategy.
• The NHF was founded in 1988 and now has 37 district offices throughout
the country .
Prevention of Rheumatic Fever and Heart Disease:
Nepalese Experience Prakash Raj Regmi*, Rosemary Wybery

25. • The NHF is a member of the World Heart Federation and supports the World
Heart Federation’s mission
“to unite members and lead the global fight against
RHD through aligning around the WHO-related target
of 25 percent reduction in RF/RHD mortality by 2025
in under 25 year olds”

26. Objectives of The national RF/RHD prevention and control
program
1. Early detection and registration of RF/RHD patients.
2. Establishment of centers for safe administration of BPG injection for
secondary prophylaxis.
3. Establishment of a national strategy for RF/RHD prevention and control with
development of RHD control toolkit.

27. Elements of the program
1) Epidemiological Studies
The NHF has developed an RF/RHD register and used as a resource for improving local
descriptive epidemiology
2) Awareness for RHD Control
Putting large hoarding boards throughout the cities; mobilizing the media; including RHD materials
in school curriculums; showing street dramas; distributing pamphlets, posters, and calendars
Mobilization of celebrities in awareness campaigns
As a result of these activities, the awareness on RHD increased by 40% (from 8% to 48%) in
schoolchildren and teachers of Nepal
3. Training of health workers.
In Nepal After completing the training, >90% of paramedics who had earlier refused to inject BPG
agreed to do it under the guidance and supervision of the NHF

28. 4. Case detection (heart screening).
World Health Organization (WHO) guidelines recommend screening for RHD in high prevalence
settings.
A 2-stage method has been used: brief clinical examination and auscultation, followed by
confirmation of the suspected cases with echocardiography.
5. Registry of RF/RHD patients.
Nepal has adopted a 3-tiered system for maintaining the RF/RHD registry:
1. Hospital register
2. National (central) register
3. Penicillin injection card
6. Delivery of medicines for secondary prophylaxis.
Given the very high burden of RF in Nepal, secondary prophylaxis with penicillin once every 3
weeks is recommended by the NHF.

29. 7. Surveillance system.
8. Evaluation and monitoring.
CONCLUSIONS
The Nepalese model of a diagonal RF/RHD control program illustrates the feasibility of care
delivery in very low resource settings.
Developing an RF/RHD registry, training paramedics, publishing recommendations and
guidelines, and securing a supply of BPG are significant achievements and advances in practice.

30. MCQS
1) Which of the following circumstances foster the transmission of
streptococcal throat infection and/or development of ARF
a) Overcrowding and Low socio economic status
b) Genetic predisposition
c) Severity, frequency and duration of streptococcal throat infection
d)All of the above

31. 2) The commonest age group affected by acute rheumatic
fever is
a) 2-4 years
b) 3-5 years
c) 5-15 years
d) Greater than15 years of age

32. 3) Which valves are commonly involved in
RF/RHD?
a. Tricuspid , mitral
b. Mitral , Aortic
c. Tricuspid , pulmonary
d. Aortic , pulmonary

33. 4. A patient with R.F comes with dancing movement, how
can you explain this movement:
a. Myopathy
b. Neuromuscular junction disease
c. Sydenham's chorea
d. Psychosis

34. 5- Which of the following is a complication of RF?
a. Valve regurgitation
b. Damage to heart muscle
c. Heart failure
d. All the above

35. 6. Which of the following is not a component of primary prevention
of ARF?
a) Avoidance of contact with a person having colds and URTI
c) Early recognition and prompt treatment of streptococcal infection
/sore throat/
d) Improved standard of living and housing conditions
e) Monthly benzanthine penicillin injection

36. References
• Park’s textbook of preventive and social medicine,25 Edition
• Harrisons principles of Internal Medicine ,19 Edition
• Man Bahadur KC. Rheumatic Heart Disease in Nepal: Current Scenario,2016
• Prevention of Rheumatic Fever and Heart Disease: Nepalese Experience
Prakash Raj Regmi*, Rosemary Wybery
• https://world-heart-federation.org/what-we-do/rheumatic-heart-disease/